New Patient Intake Form

Download a blank fillable New Patient Intake Form in PDF format just by clicking the "DOWNLOAD PDF" button.

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Complete New Patient Intake Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

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Practice:
Today’s Date:
Name: _______________________________________DOB: ______________ Chart Number: _____________
Sex:
Marital Status:
ingle
Married
Widowed
Divorced
SS#: _______________________
E-mail: ______________________________________ Spouse/Partner Name: ___________________________
Address: _____________________________________ City: _______________ State: _______ Zip: __________
Home #: ________________________ Cell #: ________________________Work #: ______________________
Pharmacy: __________________________________ Phone: _______________________
Primary Care Physician: _______________________ Phone: ______________ Date Last Seen: ____________
Address: ____________________________________________________________________________________
Employer: _____________________________________
Phone: ________________________
Address: ____________________________________________________________________________________
Primary Insurance: ___________________________________________________Are you the insured?
Insured Information
Subscriber Name: __________________________
Relationship to insured:
Phone #: ________________________________
Sex:
DOB: ___/___/___
Address: ________________________________________________________________________
Policy ID: _______________________________
Group ID: _______________________________
Secondary Insurance: _________________________________________________ Are you the insured?
Policy ID: ___________________________________
Insured Information
Subscriber Name: __________________________
Relationship to insured:
Phone #: ________________________________
Sex:
DOB: ___/___/___
Address: ________________________________________________________________________
Policy ID: _______________________________
Group ID: _______________________________
How did you find out about our practice?
Physician
Internet
Telephone book
Family member
Friend
Other: _________________________________________________
What is the reason for your visit today? _________________________________________________________________
______________________________________________________________________________________________________
How long has this bothered you? 1 2 3 4 5 6 7
days
weeks
months
years
What treatments have you tried & have they been effective? ____________________________________
_____________________________________________________________________________________________
On a scale of 1-10 (1 being no pain and 10 being the worst) what is your level of pain? ___/10
10
The pain quality is:
ther:____________
PLEASE READ AND SIGN
The above information is correct to the best of my knowledge. I understand that throughout my treatment, I am responsible for notifying the physician
and/or medical staff of any and all updates to the information listed above. __________________ _______________________ (Patient Signature)

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